2016 Section 5 Green Book

Brietzke et al

Table 1. Definition and Diagnosis of Pediatric Chronic Rhinosinusitis Statements Reaching Consensus.

Quality Improvement Opportunity

Number

Statement

Mean Outliers

Chronic rhinosinusitis (PCRS) is defined as at least 90 continuous days of 2 or more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough and either endoscopic signs of mucosal edema, purulent drainage, or nasal polyposis and/or CT scan changes showing mucosal changes within the ostiomeatal complex and/or sinuses in a pediatric patient aged 18 years or younger (Adapted from European Position Paper on Rhinosinusitis and Nasal Polyps 2012 23 ). 7.56 Management of children aged 12 years and younger with CRS is distinctly different than management of children aged 13 to 18 years old with CRS. 7 Nasal endoscopy (flexible or rigid) is appropriate in evaluating a child with CRS to document purulent drainage, mucosal edema, nasal polyps, and/or adenoid pathology (hyperplasia, infection). 7.67 Management of the children with nasal polyps and CRS is distinctly different than management of children with CRS unaccompanied by nasal polyps. 8.22 Allergic rhinitis is an important contributing factor to PCRS, especially in older children. 7.56 Adenoiditis is an important contributing factor to PCRS, especially in younger children. 7.67 The ability of adenoids to serve as a bacterial reservoir for PCRS is independent of adenoid size. 7.67

0 Promoting appropriate care

1

2

0 Promoting appropriate care 1 Promoting appropriate care 0 Reducing inappropriate or harmful care 0 Promoting appropriate care 1 Promoting appropriate care 1 Reducing inappropriate or harmful care

3

4

5

6

7

symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough with corresponding endoscopic and/ or CT findings in a patient who is 18 years of age or younger (statement 1). Strong consensus (mean Likert score above 8.00) was achieved for the statement that pediatric patients with nasal polyps should be managed differently than those without polyps (statement 4). The panel reached consensus that age was an important distinguishing factor in the diagnosis of PCRS, with adenoid disease (independent of adenoid size) being a prominent factor in younger chil- dren and allergic rhinitis being a more important contribut- ing factor in older children (statements 2, 5-7). Lastly, consensus was also reached that nasal endoscopic (flexible or rigid) is appropriate and useful in the diagnosis of PCRS (statement 3). There was no consensus regarding the contri- bution of gastroesophageal reflux disease (GERD) to PCRS ( Table 2 , statement 8). Medical Treatment of PCRS For medical management of PCRS, 5 statements reached consensus by the panel and 4 statements failed to reach con- sensus (see Table 3 ). Consensus was reached that daily, topical nasal steroid spray as well as daily, topical nasal irri- gations are beneficial adjunctive medical therapies for PCRS (statements 11 and 12). Regarding antibiotic therapy, the panel failed to reach consensus on the statement that appropriate antibiotic therapy for PCRS includes a mini- mum of 10 consecutive days of an antimicrobial medication that is effective against typical rhinosinusitis pathogens (statement 14). However, the panel did reach consensus that

20 consecutive days of antibiotic therapy may produce a superior clinical response in PCRS patients compared to 10 days of antibiotic therapy ( Table 2 , statement 9). The panel also reached consensus that culture-directed antibiotic ther- apy may improve outcomes for PCRS patients who have not responded to empiric antibiotic therapy (statement 10). The panel did not agree that medical therapy for PCRS should include treatment for GERD when signs or symp- toms of GERD are present ( Table 2 , statement 15), instead agreeing that empiric treatment for GERD is not a benefi- cial adjunctive medical therapy for PCRS (statement 13). Additionally, the panel did not reach consensus that the current evidence supports a role for topical antibiotic ther- apy or antral irrigation in managing children with PCRS ( Table 2 , statements 16, 17). Adenoiditis/Adenoidectomy For adenoiditis/adenoidectomy, 4 statements reached con- sensus by the panel and 1 did not (see Table 4 ). Strong consensus was reached regarding the effectiveness of ade- noidectomy as the initial surgical therapy for patients aged up to 6 years, and measurably less consensus was obtained for patients age 6 to 12 years (statements 18, 19). However, the panel could not reach consensus on whether adenoidectomy was an effective first-line procedure for patients aged 13 years and older with CRS ( Table 2 , state- ment 22). The panel agreed that adenoidectomy can have a beneficial effect in pediatric patients with PCRS that is independent of ESS (statement 20). There was strong con- sensus, in fact the highest Likert score of any statement in

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